Provider Demographics
NPI:1760976542
Name:PERTAB, VANESSA (SPECIAL EDUCATION)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:PERTAB
Suffix:
Gender:F
Credentials:SPECIAL EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 30TH ST APT F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-1726
Mailing Address - Country:US
Mailing Address - Phone:646-287-0147
Mailing Address - Fax:
Practice Address - Street 1:8403 57TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4833
Practice Address - Country:US
Practice Address - Phone:718-899-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2572596103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst